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Investigation and inquest
On 1st March 2024 this Court commenced an investigation into the death of Elizabeth Grace Holder, aged 88 years. The investigation concluded at the end of the inquest on 24th July 2024 when the Court returned a narrative conclusion:
“Elizabeth Grace Holder died in hospital on 24th February 2024 due to complications of a fall that occurred whilst recovering from surgery as an inpatient. At the time of the fall, Mrs Holder was not properly supervised.”
Mrs Holder’s medical cause of death was determined as;
1a Intraparenchymal haematoma
1b Fall
II Neck of femur fracture (corrected), intraparenchymal haemorrhage
Circumstances of the death
Elizabeth Grace Holder was an 88-year-old woman with co-morbidities, restricted mobility and a history of falls.
Elizabeth was admitted to hospital on 29th December 2023 by ambulance following a fall, she was admitted to the trauma unit and underwent a surgical repair of a broken hip. Mrs Holder was noted to be at high risk of falls and had been assessed to require an enhanced level of nursing care, initially requiring 1:1 nursing care.
Mrs Holder had a difficult recovery and developed a surgical wound infection. During her inpatient recovery period the patient lost physical reserve and was observed to be increasingly confused, despite this nursing care was reduced to a 1:2 ratio.
On 15th February 2024 it was noted that Mrs Holder had declined further, she was markedly confused and underwent diagnostic tests resulting in a queried diagnosis of a transient ischaemic accident.
On the evening of 19th February 2024 Elizabeth was observed to be confused and anxious. Mrs Holder had asked to be taken to the lavatory, her request was refused, and she was told to use the commode by a male Health Care Assistant (“HCA”).
The HCA did not believe that it was appropriate for him to observe Mrs Holder in the use of the commode and allowed her to proceed unsupervised behind a ward bay curtain. The HCA did not consider alternative, safer strategies, neither asking the female nurse allocated to Mrs Holder on the same shift to undertake supervision, nor offering to supervise use of the commode in the presence of a chaperone.
The fall resulted in a fatal intra-cerebral bleed.
Coroner’s concerns
1. The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death.
2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub-optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to;
a. Identify and reflect upon failings in care,
b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s death.
Information checked against the published report and official responses